hepatic hydrothorax hepatic hydrothorax.p… · thoracentesis •30% other cause: spontaneous...

Hepatic hydrothorax

Sasinee Tongprasert, MD

Samitivej Srinakarin Hospital

Ramathibodi Hospital

DEFINITION

• Significant pleural effusion, usually greater than 500 mL, in a cirrhotic patient, without an underlying pulmonary or cardiac disease

• Prevalence 5–12%

• 85% Rt, 13% Lt, 2% bilateral

Sawant P, et al. International Journal of Hepatology 2011:1-11 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

PATHOGENESIS

• Hypoalbuminemia—decreased colloid osmotic pressure

• Azygos veins hypertension

• Transdiaphragmatic migration of fluid via lymphatic channels

• Leakage of ascitic fluid via diaphragmatic defects

Roussos A, et al. Journal of Gastroen Hepatol 2007;22: 1388–1393 Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320

Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141

Truninger K, et al. Schweiz Med Wochenschr 2000;130: 1706

PATHOGENESIS

PATHOGENESIS

CLINICAL MANIFESTATIONS

• Shortness of breath, cough, hypoxemia, and/or chest discomfort

• Acute tension hydrothorax (less common)

DIAGNOSIS

CXR

Woo Jin Lee, et al. The Korean J Hepatol 2011;17(4):292-298

Thoracentesis

• 30% other cause: spontaneous bacterial empyema (SBEM), tuberculosis, adenocarcinoma, parapneumonic empyema

• 85% of right side and 35% of left side is simple hepatic hydrothorax

• Cell count, Gram stain and culture in blood culture bottles, and serum and fluid protein, albumin, and LDH

Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

DIAGNOSIS

• Cell count < 500/mm3

• PMN count < 250/mm3

• Protein concentration < 2.5 g/dL

• Pleural fluid/serum total protein ratio < 0.5

• Pleural fluid/serum LDH ratio < 0.6

• Pleural fluid/serum albumin gradient > 1.1

• pH >7.4

• Pleural fluid glucose concentration similar to that of serum

DIAGNOSIS


Criteria

• PMN > 250 cells/mm3 and positive culture or

• PMN > 500 cells/mm3 and negative culture

• Absence of pneumonia on CXR

Siddappa PK , et al. Trop Gastroenterol 2009;30(3): 135–141 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

Spontaneous bacterial empyema (SBEM)

• Incidence 13-16%

• 40% not associated with SBP

• Direct spread of the infection through the diaphragmatic defects and enteric microorganisms reach the pleural space through bacteremia

• Fever and pleuritic chest pain, encephalopathy or unexplained deterioration in renal function


Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

• The etiologic agents: E. coli, Streptococcus, Enterococcus, Klebsiella

• Rx: Third-generation cephalosporin

Albumin, antibiotic prophylaxis

• Risk factors: low levels of pleural fluid C3 or total protein, and a high Child-Pugh score

• Mortality 20%


Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

Intraperitoneal injection of 99mTc-sulphur colloid or 99mTc-human serum albumin

• Gold standard: sensitivity 71%, performing a thoracentesis prior increase sensitivity nearly 100% and specificity 100%

DIAGNOSIS


• Investigation for primary cardiopulmonary disorders: CT chest, Echocadiography

Radiology March 2011;258(3):776-784

DIAGNOSIS

MANAGEMENT

Candidates for orthotopic liver transplantation

• Definitive treatment

Medical management

• Sodium-restricted diet: 2 g/ day

• Diuretics: renal excretion of Na > 120 mEq/day

MANAGEMENT

Therapeutic thoracentesis

• "2 L rule"

• Risk of pulmonary edema and hypotension

• Complication: pneumothorax, hemothorax

• Coagulopathy: not contraindication

• Cr > 6 mg/dl increase risk bleeding

• Placement of chest tubes in patients with hepatic hydrothorax can result in massive protein and electrolyte depletion, infection, renal failure, and bleeding

• Relative contraindication

Orman ES, Lok ASF. Hepatol Int 2009;3:582–586

MANAGEMENT Transjugular intrahepatic portosystemic shunts • Response rates 70-80% • Largest study by Dhanasekaran 73 patient: 59% CR, 20% PR and 21% NR short term survival 30, 60,90 d: 81, 78, 72% long term survival 1, 3, 5 yr: 48, 26, 15%

• Standard treatment for refractory hepatic hydrothorax

• Contraindications: age > 70, significant hepatic encephalopathy, large portal vein thrombosis, right-sided heart failure, elevated pulmonary arterial pressures, and MELD score > 18

Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

MANAGEMENT

Surgical interventions

• Surgical repair of diaphragmatic defects: small report from Milanez: 21 Patients

Success 48% Morbidity 57.1% Mortality 38.9%

• Pleurodesis—injection of a sclerosing agent, Video-assisted thoracoscopy (VATS): limit data

Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10

Improve clinical 72.7% but mortality 45.5%

• Other treatment options — Splanchnic vasoconstrictor drugs (Octreotide, Terlipressin): case report

MANAGEMENT

SUMMARY

• Pleural effusion in a cirrhotic patient, without an underlying pulmonary or cardiac disease

• Most right side

• Leakage of ascitic fluid via diaphragmatic defects

• Thoracentesis should perform

• SBEM

• Intraperitoneal injection of 99mTc-sulphur colloid or 99mTc-human serum albumin: gold standard

SUMMARY

hepatic hydrothorax hepatic hydrothorax.p… · thoracentesis •30% other cause: spontaneous...

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